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Equality and Human Rights Commission

Case studies: healthcare and service providers facilitating access to healthcare for people seeking asylum


Contents

1 | Introduction............................................................................................................3

1.1 Why have we produced this document?............................................................3

1.2 Who is this document aimed at?........................................................................4

2 | Suggestions for a human rights-based approach to accessing healthcare for people seeking asylum................................................................................................5

4 | How these case studies might be used..................................................................8

5 | Case studies..........................................................................................................9

5.1 The Assist practice............................................................................................9

5.2 Doctors of the World Safer Surgeries Advocacy Programme..........................12

5.3 Asylum Health Bridging Team.........................................................................15

5.4 Doctors of the World Women and Children’s Clinic.........................................18

5.5 The Healthy London Partnership.....................................................................21

5.6 Health Integration Team Sheffield...................................................................23

5.7 Family Refugee Support Project......................................................................26

5.8 TS4SE.............................................................................................................29

6 | Other examples of innovative practice.................................................................33

Contacts....................................................................................................................39

1 | Introduction

Equality and Human Rights CommissionPublished: April 2019 2

http://www.equalityhumanrights.com/


1.1 Why have we produced this document?

Our job is to protect and promote the human rights of everyone in Britain.

The right to health exists in domestic, European, and international law and imposes obligations on the State to make sure that everyone enjoys the highest attainable standard of physical and mental health. This right applies to everyone, regardless of who you are or where you come from.

Our review of the most disadvantaged groups in Britain showed that people seeking asylum face barriers in accessing public services, including health services. They are also more likely to have particular healthcare needs caused by distressing experiences and the traumatic effects of fleeing to a different country. We published research to understand the evidence and lived experiences of access to healthcare for people seeking and refused asylum in Great Britain. This highlighted some of the key barriers people faced and supported us to make recommendations to governments and healthcare institutions for how to address them.

One key gap in this research was highlighting where healthcare providers and other services were working to facilitate access to healthcare for these groups. The case studies in this document aim to address this gap, highlighting where and how practice is happening that specifically aims to tackle the barriers people seeking or refused asylum are facing when trying to access healthcare, drawing out human right-based approaches, where they are applied.

1.2 Who is this document aimed at?

Organisations working with people seeking asylum

Healthcare policy makers

Asylum support policy makers

Asylum accommodation and support providers

Healthcare professionals

Healthcare commissioner



https://www.equalityhumanrights.com/en/publication-download/making-sure-people-seeking-and-refused-asylum-can-access-healthcare-what-needshttps:/www.equalityhumanrights.com/en/publication-download/making-sure-people-seeking-and-refused-asylum-can-access-healthcare-what-needs

https://www.equalityhumanrights.com/en/publication-download/making-sure-people-seeking-and-refused-asylum-can-access-healthcare-what-needshttps:/www.equalityhumanrights.com/en/publication-download/making-sure-people-seeking-and-refused-asylum-can-access-healthcare-what-needs

https://www.equalityhumanrights.com/en/refugees-asylum-and-immigration


https://www.equalityhumanrights.com/sites/default/files/is-england-fairer-2016-most-disadvantaged-groups-migrants-refugees-asylum-seekers.pdf


2| Suggestions for a human rights-based approach to accessing healthcare for people seeking asylum

A human rights-based approach puts human rights at the heart of policy and practice. In our ‘Healthcare Access Guide’ we have highlighted suggestions for how a human-rights based approach might be applied in healthcare settings.

Human rights apply to everyone. However, some groups need extra attention and support to make sure they can enjoy their human rights to the same level as everyone else. People seeking asylum are considered to be members of a ‘particularly underprivileged and vulnerable population group in need of special protection’ (Case of M.S.S. v Belgium and Greece, Application number 30696/09).

In healthcare, a human rights-based approach includes the following characteristics:

Healthcare law, policy and practice is in line with international human rights standards, and are reviewed and monitored through processes that are effective and transparent with clear accountability.

People seeking asylum, their dependants and their communities should have easy access to healthcare and information about their rights in a language that they understand. They should be able to actively participate in shaping the policies and services that affect them.

Staff are empowered with the knowledge and skills to consider human rights, including through being provided with appropriate training.

Leadership is committed to human rights.

Everyone enjoys the right to non-discrimination and the right to privacy, and specific attention is paid to individuals in vulnerable situations and disadvantaged groups.



https://www.equalityhumanrights.com/en/publication-download/access-healthcare-guide-organisations-working-people-seeking-asylum


Below are some common principles used in England, Scotland and Wales by healthcare providers to implement a human rights-based approach to healthcare:

FREDA principles

The Care Quality Commission (CQC) uses the following human rights principles to make sure that healthcare in England is safe, effective, compassionate and high-quality:

Fair: People using healthcare services have access to clear and fair processes for decision making about care and treatment, and for getting their views heard.

Respectful: People are valued as individuals, and what is important to them is viewed as important by healthcare services.

Equal: People do not experience discrimination in accessing services.

Dignified: People are treated with compassion, in a way that values them as a human being and supports their self-respect.

Autonomous: People can exercise the maximum amount of control and choice possible in their care and treatment.

PANEL principles

Health Improvement Scotland, and older people and children’s commissioners in Wales, use PANEL principles:

Participation: People should be able to voice their experiences and take part in decision making. Policies and practice should support people to participate in society and lead fulfilling lives.

Accountability: Organisations and people should be accountable for realising human rights. There is a level below which service standards must not fall, but above that level the journey towards full realisation of human rights should be understood as progressive.

Non-discrimination: Everyone has the same rights regardless of their ethnicity, gender, income, religion, etc.

Empowerment: People, communities and groups should have the power to know about and claim their rights to make a difference to their lives.

Legality: All decisions should comply with human rights legal standards.

You will see examples of what this looks like in practice, highlighted throughout the case studies.




3 | Common factors identified by the services featured in the case studies that they feel facilitate access to healthcare for people seeking and refused asylum

Taking time to gather insights to develop an understanding of the unique needs of asylum seeking communities (including at different points across the asylum process).

Using this insight to plan services in a patient-centred way that meets these needs, for example by offering extended appointment times to cover the more complex needs of people seeking asylum.

Hiring or training experienced staff to understand the unique needs of communities who have particular vulnerabilities or who have complex needs.

Involving patients in the planning and improvement of services.

Ensuring that services take a holistic approach to care, where the patient is treated as a whole person, not just a symptom. This includes working collaboratively with other services (such as accommodation providers), to understand and meet the needs of people seeking asylum.

Having senior level support, such as Clinical Commissioning Groups or trust leaders, to advocate for the service and why it is needed.

Sharing knowledge, guidance and best practice with other organisations/stakeholders in how to adequately support people seeking asylum across a holistic range of needs.




4 | How these case studies might be used

We hope that these case studies can support organisations when planning or improving services, especially if they are looking at strengthening their human rights-based approach to care for people seeking asylum. Our Healthcare Access Guide can also be used to understand more about entitlements to healthcare for these groups at different stages of the asylum process. This guide also contains a checklist for consideration to ensure a human rights-based approach for people in the asylum system.





5 | Case studies

5.1 The Assist practice

Overview

The Assist practice (Assist) , part of the Inclusion Healthcare Social Enterprise Community Interest Company in Leicester, is a medical centre specifically designed to provide people seeking asylum with healthcare within Leicester. Assist addresses the primary health needs of people seeking and refused asylum (including blood


Checklist for consideration by healthcare service providers and commissioners to ensure a human rights-based approach for people in the asylum system:

Are healthcare professionals (including frontline staff such as receptionists) trained on the rights and entitlements of those seeking asylum, the problems they face in accessing healthcare, and their cultural sensitivities?

Is the process for registering with a GP well understood by staff and patients?

Are professional interpreters provided without the person having to ask for one?

Are services commissioned locally that meet the healthcare and access needs of those seeking asylum?

Are healthcare staff trained to explore pro-actively and sensitively with patients whether they require an interpreter or other language support to ensure there are no barriers to communication during appointments?

Are there ways for people who don’t speak English and have limited money and/or internet access to register with a GP and to make appointments?

Is healthcare provided in a person-centred way, with clear consent and involvement by patients in their care, and how is this provision monitored?


https://assistpractice.co.uk/


tests, vaccinations, contraceptive advice and cervical screening) and supports their transition into mainstream practice when they are granted refugee status.

Staffing structure

Four part-time GPs, two part-time nurses, and as of August 2018, Assist has become a training practice for GP registrars.

Funding

Assist are commissioned as an Alternative Provider Medical Service by their local Clinical Commissioning Group.

Why the service was needed

Leicester is an asylum dispersal area. This means that it frequently receives new people seeking asylum. When people arrive in the area, everyone needs to be registered with a GP and some people require additional healthcare services. It became apparent that local primary care settings could not cope with the volume of new patients and didn’t have the skills and resources needed to support the unique needs of these new patients. As a result, the primary care trust funded a pilot service to deliver specialist care while people were in the asylum process.




Impact of the practice

As Assist grew, local health professionals developed an understanding of the specific and often complex healthcare needs of people in the asylum system. As a result, the local Clinical Commissioning Group (later responsible for the service) recognised the opportunity to improve public health, vaccinations and screening and agreed to commission Assist as an Alternative Provider Medical Service. This means that Assist were able to provide enhanced and additional primary medical service to meet these additional needs, as part of the local primary care offer. In 2018. Assist was rated as “Outstanding” by the CQC (read the CQC report).

Unique elements that help to meet the healthcare needs of people in the asylum system

Location

An important condition of success for Assist in meeting the healthcare needs of people in the asylum system is choosing a central location with good transport links, as people seeking asylum are more likely to be dispersed all over the city.

Understanding complex needs

By working with, and building an understanding of the specific health needs of people seeking asylum, the team understood that a mainstream primary care approach would not work for this group. In particular, they identified short appointments times associated with GP consultations were not adequate. They found that people seeking asylum have a wide range of healthcare needs, meaning that they may need more time in consultation. For example, patients may also have faced trauma as a result of their experiences prior to seeking asylum. Assist gives new patients a 45 minute consultation and registered patients a minimum of 15 minutes per appointment (increased to 30 minutes if the patient requires an interpreter). Patients also have immediate access to translation services at every point of contact with the service, and conference calls are held with translators.

A welcoming environment

Assist places much emphasis on making the environment welcoming, calm and safe for patients from the outset. They have spent six months looking at ways to improve their service, involving patients throughout the process to understand how the practice could better meet their needs. For example, there was previously a large glass screen between receptionists and patients, which created a barrier to good



https://www.cqc.org.uk/sites/default/files/new_reports/AAAH2220.pdf


communication. They removed this screen and receptionists were given on-site training on how to interact with patients.

Staff at the practice are experienced in working with clients with additional or particular needs and undergo ongoing and bespoke training on the asylum seeking process, including the relevant forms involved and the process for people after a positive or negative decision. This means that they are able to provide a welcoming, patient-centred approach to caring for patients. This approach has been very effective, with surveys showing a high level of satisfaction from patients registered at the practice in terms of being treated with compassion, dignity and respect.

A holistic and collaborative approach

The Assist Practice adopts a holistic approach to healthcare, and joins with other services to share insight and resources. During the ‘new patient consultation’ patients are educated about the NHS healthcare system and pharmacies so that they know how to use primary care services. This allows GPs at The Assist Practice to concentrate specifically on patient’s health issues.

Patients who are successful in their asylum claim are registered with another practice within 6–8 weeks of the decision, although occasionally some are kept on if they are too unwell to move practices. Assist educate patients so that they are ready to move on to mainstream practices. They also support patients to register with mainstream practices as many people often find it very difficult to do on their own. Assist provide a healthcare assistant who acts as a patient advocate and travels to appointments with patients to secondary care services where required.

To deal with the wider determinants of health Assist have produced a booklet for all patients about free things to do in the local area including where to access food banks, social activities for adults and children’s English classes. They also arrange trips to a local farm and a Christmas party through Assist’s community fund. The British Red Cross hosts clinics in the Assist practice so that they can jointly support patients with asylum claims, housing appointments with Supporting Tenants and Residents (STAR- a housing-related support service for people arriving in Leicester), finding suitable accommodation, and accessing legal representation.

Assist also works closely with other organisations. They regularly attend Multi-Disciplinary Team (MDT) meetings with external voluntary and statutory agencies, which enables organisations to work together to improve the services they provide for people seeking and refused asylum.




Ongoing support for people who are refused asylum

Those who are unsuccessful in their asylum claim continue to be supported by Assist. As well as continuing to address healthcare needs, Assist also help people who have been refused asylum with other basic needs such as referrals to local charities and food banks, supporting the completion of asylum support application forms and write supporting letters required at short notice by other agencies such as the Home Office and solicitors. As patients have no funds to pay for these Assist do not charge for these services.

Contacts

Deborah Brunger ([email protected])

Anna Hiley ([email protected])

5.2 Doctors of the World Safer Surgeries Advocacy Programme

Overview

The Doctors of the World (DotW) Safe Surgeries, launched in January 2018. It is a network of GP practices committed to tackling barriers preventing access to primary care and promoting the health of everyone in their community – regardless of their nationality or immigration status, and providing free training and practical resources to health professionals. The network connects participating practices together to share resources, training, policy updates and to enable peer-to-peer support.



https://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/safe-surgeries-initiative/?nabm=0

mailto:[email protected]



Staffing structure

Two full-time policy officers and three part-time GP Champions in local Safe Surgery areas.

Funding

Trust for London and the Open Society Foundation fund staff positions for the Safe Surgeries team.


In 2017, DotW saw 1717 patients at their clinic, where they treat people seeking asylum, undocumented migrants, homeless people and other patients in vulnerable situations who cannot access healthcare elsewhere.

The Safe Surgeries network aims to improve access to primary care for these groups, in particular registering with a GP. Around 20% of attempts by DotW caseworkers to register the attendees of their clinic with an NHS GP ended in refusal, with a lack of ID, proof of address or immigration status being the most common reasons for refusal, none of which are valid reasons to refuse someone access to a GP.

Impact of the service

There are currently 105 Safe Surgeries. Since launching the initiative, DotW has trained over 1,200 people on refugee and migrant access to healthcare, including the Greater Manchester Health and Social Care Partnership, who are responsible for commissioning primary care for 2.8 million patients. DoTW also held a session at the 6th Annual London GP Trainee Conference. The training covers legal entitlement to NHS services and barriers to healthcare experienced by people seeking asylum.

Unique elements that help the healthcare needs of people in the asylum system

Engaging and training health professionals

Engagement and drive from local GPs has been an important factor for success. There has been a lot of will and desire from GP surgeries to adopt an inclusive approach to healthcare. However, as GPs are so busy and under pressure, they require help, support and resources to make it as easy as possible for them to participate in this initiative.




Therefore, DotW engage with primary care providers and commissioners to support them to adapt their services in a way that makes them more accessible for people who face barriers to accessing healthcare services. To assist with this, DotW have produced a Safe Surgeries Toolkit that provides guidance and support for frontline services in creating an environment in which everyone in their community can access the healthcare that they are entitled to. The toolkit explains the issues refugees, people seeking asylum and other groups in vulnerable situations face in trying to access NHS services and outlines seven key steps that practices can take to make their services more accessible. For example, one of these steps includes making sure that staff know that they should not ask to see a passport, visa or identity document when registering a patient.

DoTW have also created a toolkit for commissioners, which explains the benefits of Commissioning Safe Surgeries to be implemented in their local area. These benefits include:

improving access to equitable and quality care

supporting practices to score highly in CQC inspections as Effective, Caring and Responsive surgeries

promoting healthy communities

The Toolkit also explains how commissioners can help to support the implementation of Safe Surgeries, by encouraging both clinical and non-clinical GP practice staff to ensure their registration policies are in line with NHS England guidance.

Building local support

In the West Midlands, DotW held a Safe Surgeries training workshop, attended by healthcare professionals and commissioners. During this workshop one of the first Safe Surgeries in the West Midlands spoke to attendees, sharing experiences from the local DotW GP champion and a local refugee patient who had experience of being excluded form NHS services. This event led to 16 more practices joining the network.

Support from local CCGs has also been very influential in encouraging local GP practices to sign up to becoming Safe Surgeries. For example, there has been a high level of support for the Safe Surgeries initiative from Central Manchester CCG, who have expressed support for providing access to healthcare for people excluded from mainstream healthcare including undocumented migrants. The CCG invited all GPs in the area to receive training, and this has led to a culture change around the importance of an inclusive approach to primary care.




Allaying fear

DotW found that a common misconception amongst GPs of becoming a Safe Surgery was that adapting their practices may open the ‘floodgates’ to lots of new registering patients. Those who signed up to the Safe Surgeries initiative found that implementing changes and having a more inclusive policy did not actually impact negatively on their practice. One Safe Surgery reported that:

‘becoming a Safe Surgery means our clinical and non-clinical staff are more aware of the issues surrounding access to healthcare for vulnerable migrant groups, including possible barriers to accessing services. We also hope that identifying as a Safe Surgery makes us more visible and approachable to these groups and more inclusive in general.’

(Source: Dr Jenny Akurst (GP), Clapham Park Group Practice)

Contact

Anna Miller ([email protected])

5.3 Asylum Health Bridging Team

Overview

Formed in 2011, the Asylum Health Bridging Team (AHBT), part of NHS Greater Glasgow and Clyde (NHSGGC), act as a bridging service for people seeking asylum to access other mainstream services. The team:

provide information and advice on understanding and accessing appropriate health services

undertake mental health assessments and refer, as appropriate, to other mental health services

support and monitor GP engagement for those moving through Initial Accommodation into mainstream Dispersed Accommodation

support mainstream services to understand rights and obligations for people in the asylum system, including offering training sessions and attending community and asylum forums (for example, vulnerable household forums, Scottish Asylum Stakeholders Forum, and Glasgow Integration Network)

provide undergraduate and postgraduate online training for the NHS board





Staffing structure

The team consists of 0.5 team leaders, 2 psychiatric nurses, 4 general nurses, 1.5 healthcare support workers, and 2 administrative staff.

Funding

The service is funded through NHSGGC and now part of Glasgow City Health and Social Care Partnership, which is the public body set up for integration of health and social care in Scotland.

Why the service is needed

On a national level, the health needs of people seeking asylum are a long-term priority for the Scottish government which, through its 2018-22 ‘Refugee Integration Strategy’, seeks to facilitate better access to mainstream services such as education, housing, health and employment. The strategy emphasises the importance of adopting a human rights-based approach in order to empower people to know and claim their rights, participate in decisions that affect them, and maintain and improve their wellbeing independently. The strategy specifically seeks to ensure that refugees and asylum seekers are able to look after and improve their own health and wellbeing and have positive experiences of using health and social care services.

The Scottish Government also aspires to be more responsive to the needs of refugees and people seeking asylum. As part of this aspiration relevant policy, strategic planning and legislation are informed by the underlying social factors that impact the health and wellbeing of people seeking asylum and granted refugee status.

A local level review by the NHSGGC, of the needs of people seeking asylum and the services available to them identified that there was a need to provide specialist support to people arriving in Glasgow.

The AHBT was therefore set up to facilitate meeting these government priorities and strategies and the needs of local asylum seeking populations.


AHBT has enabled newly arrived people in the asylum process with quicker access to healthcare through assisting them with GP registration. Of the approximately 2500-3000 new arrivals AHBT receive each year, 70% go on to be successfully registered with a GP (compared to 40% prior to AHBT).




Unique elements that help meet the needs of people in the asylum system

A supportive national policy environment

Everyone who is resident in the UK can access free emergency and primary healthcare, such as GP surgeries and A&E. In England, people whose claim for asylum has been refused are sometimes chargeable for some secondary care services (e.g. non-emergency hospital care). However, in Scotland, if someone has been in the asylum system at any point, they are entitled to healthcare free of charge.

Refugees, people seeking asylum and those who have had their claim refused who are living in Scotland are entitled to register with a GP, access emergency health services, register with a dentist and have eye tests. They can also access specialist healthcare (through a GP referral), including maternity care, mental health services and any other services for specific conditions. The Scottish government’s ‘Refugee Integration Strategy (outlined above) is also facilitative in ensuring that people seeking asylum are able to access, and meaningfully participate in, healthcare.

This wider policy context has created an environment that supports the operation of the AHBT’s day-to-day work, and its success in providing newly arrived asylum seekers with access to healthcare.

AHBT report that within NHSGGC, people seeking asylum and people who are homeless are identified and treated as having standalone protected characteristics in addition to those listed in the Equality Act 2010. You can find out more about protected characteristics, the Public Sector Equality Duty, and how public sector bodies have a duty to integrate considerations of equality in their day to day business here.

Partnership and collaboration

Vital to the success of AHBT’s is having a good working relationship with advice services and the providers of accommodation for supported people who are seeking or have been refused asylum, currently delivered by Serco. The nature of AHBT’s service means that there is a lot of information that needs to be shared regularly between partners, such as receiving notification when a person seeking asylum has arrived in Glasgow. However, this information exchange can be challenging, as any sharing has to be in line with GDPR rules and confidentiality. The team often discuss this at the Initial Assessment stage) and ensure that, if breaching confidentiality, their decision fits within the legal framework.



https://www.equalityhumanrights.com/en/advice-and-guidance/public-sector-equality-duty


A responsive team

AHBT consistently keeps track of the demographics of people in the asylum system who arrive in Glasgow in order to identify patterns and deal more efficiently with corresponding healthcare needs. For example, 20 years ago, Glasgow was receiving mostly families seeking asylum, 10 years ago this changed to single people, and in the last 18 months the trend has reverted back to families. It is important to collate and monitor this information to ensure each group has access to appropriate health professionals.

Contact

Ann Forsyth ([email protected])

5.4 Doctors of the World Women and Children’s Clinic

Overview

Doctors of the World’s (DotW) Women and Children’s clinic is a specialist primary care health clinic in Bethnal Green, London, which started in June 2015. It is run by healthcare professionals, who see any woman or child who has been unable to engage with the NHS, either because they are chargeable for some secondary care services, or because of misperceptions about entitlement.

The work of the clinic includes advocacy support for patients to ensure that women receive treatment from mainstream health services, as well as direct healthcare support.



https://www.doctorsoftheworld.org.uk/



While the clinic does not serve as an alternative or substitute to secondary care, the clinic has doctors, nurses and midwives who are able to spend a substantial amount of time with patients to explore and try to address all problems and needs a patient has. They identify all types of issues (including social welfare issues) that NHS services traditionally find it difficult to deal with. Pregnant women who attend the clinic have weekly follow up consultations throughout their pregnancy and staff can help resolve housing, food and clothing needs. Staff can also address any safeguarding needs and safeguarding risk assessments are conducted where patients can be referred to child protection teams and other services that provide safety and support to people in vulnerable situations.

Translation services are also available so that patients can always communicate in their preferred language.

Staffing structure

There are 0.4–0.8 members of staff at the clinic. Over the last 3 years, as funding has increased, the part time staff role has increased from 2 to 4 days a week. The clinic is also supported by 2-3 volunteers. Clinic time (the time that patients can come to the clinic) has increased from half a day twice a month to half a day a week. Staff work beyond these times to coordinate the clinic and follow up work with individual patients.

Funding

The clinic is partly funded by a private foundation and part funded by a grant from Department for Digital, Culture, Media & Sport (DCMS). It has been funded since 2015, initially for 2 days a month, and weekly since 2018 (when the DCMS grant came into effect).


The clinic was created on the understanding that it is good practice to have a women’s only space given that women accessing DotW’s clinics have a higher than average exposure to violence, and a recognition that pregnant women face particular barriers to accessing healthcare and require specialist and time-dependent treatment.

Specific challenges for pregnant women include fear of being arrested due to potential sharing of their data with the Home Office, or fear of being charged for services. All people seeking asylum are exempt from healthcare charges including




maternity services. For some people who have been refused asylum in England, they may have to pay for some healthcare. However, maternity care should always be provided without the requirement for upfront payment. DotW report seeing billing letters to pregnant women that threaten to discontinue antenatal care if the patient does not pay a deposit of £6,500 upfront or letters threatening to report them to the Home Office if they cannot pay.

The Equality and Human Rights Commission’s (EHRC) research in to the evidence and lived experience of access to healthcare for people seeking asylum has highlighted similar barriers faced by pregnant women including fear of upfront charging causing them to delay or avoid antenatal or other maternity care.

The EHRC ‘Healthcare Access Guide’ highlights the entitlements to healthcare for people seeking asylum, drawing on current Home Office guidance.


DoTW have worked to build good relationships with hospitals, which has been supportive in facilitating access to healthcare for their patients. They report that the creation of this clinic, and its work in building these relationships, has been crucial in ensuring that women are able to access maternity services.


A focus on patients

DotW has a unique support structure in place to signpost and refer to a wide range of other (non-DotW) support services such as housing advice, immigration advice, debt advice, food banks and community support groups. DotW report that the majority of people they see are not accessing any NHS services, so having this support, alongside a more holistic package of support measures, is unique.

A safe place

In keeping with the aim of the clinic to be a women’s only space, DotW place emphasis on the clinic providing a safe space for patients. Having a reputation of being a safe place that will not report patients to the Home Office and does not carry out checks on immigration status or ask for proof of address, but provides care first and foremost, has a very positive impact on patients.

One patient reported that:






‘When I first went to hospital, a staff member said “we can’t work on you because you have to pay too much money”. It traumatised me a lot. You’re pregnant, you don't have any support, you get told that “if you don't have a red passport you don't belong here”. I thought I was going to have a baby on the street. The [Doctors of the World] team they connected me to organisations. Then I got a midwife and a GP. I got a baby box. Life is moving forward. …. Doctors of the World is like my new family, I am so grateful.’

Contact

Anna Miller ([email protected])

5.5 The Healthy London Partnership

Overview

The Healthy London Partnership (HLP), along with Healthwatch London and homeless charity, Groundswell, have produced ‘my right to access healthcare’ cards to help groups who have historically faced barriers registering and receiving treatment at GP practices such as homeless people and people seeking asylum.

The cards are available to people irrespective of their immigration status, including people seeking and refused asylum; the card specifically states ‘My immigration status does not matter’.

People who use the card are able to prove what their rights are, enabling their health needs to be addressed.



https://www.healthylondon.org/resource/my-right-to-access-healthcare-cards/

https://www.healthylondon.org/



Staffing structure

Not applicable.

Funding

NHS in London have funded the development of the ‘my right to access healthcare’ cards.


The concept of the cards came about through HLP’s homeless health programme, which looked at how homeless people’s health needs could be better met. Groundswell’s, ‘More than a Statistic’ research (commissioned by the London Homeless Health Programme in 2016) showed that one of the key barriers to homeless people getting healthcare, is registering and making use of a GP practice.

People who have been refused asylum with no recourse to public funds are at a high risk of homelessness. In 2016/17, 53% of people sleeping rough in London were non UK nationals, and many face difficulty accessing public funds and services (including health services) despite being entitled to them.

The cards can be used to remind GP receptionists and other practice staff of the national patient registration guidance from NHS England. This guidance states that you do not need an address or identification to register. Many people are not aware of this and this results in people being incorrectly refused access to healthcare.


60,000 cards have been distributed across services in London since December 2016, being delivered to shelters, day centres, food banks, drop in centres and other community and voluntary organisations across London. The cards have been distributed to 1500 GP practices. HLP also produce guidance for individuals and organisations on how to use the cards.

Surveys conducted by HLP with practices in London show that most staff find the training invaluable and has led to a difference in how they treat people presenting at their practice. People who have used the cards report feeling empowered and more confident to assert their rights to healthcare.





Training and support for NHS professionals

Getting buy-in and support from healthcare professionals, NHS bodies and homeless charities was vital to the success of this initiative. HLP reported that NHS bodies can be resistant to initiatives such as this, so it was important to get the message across to people about how important it was, and how it links with existing NHS guidance and regulations, such as the Primary Medical Care Policy and Guidance Manual.

Moreover, it was important for HLP not to just roll out the cards for people to use, but also to provide guidance and support for practice staff. In this regard, to support implementation, HLP have worked with Pathway, a homeless charity, to create an eLearning training package for GP receptionists and practice managers. It covers the specific issues faced by patients in accessing healthcare and best practice in supporting and treating them, ensuring that all practice staff are aware of the processes and respect people’s rights. The eLearning also covers immigration issues and how they relate to access to health services as HLP were keen to make clear that immigration status does not affect ability to register with a GP and to receive primary care.

Contact

Steven PIDGEON (Healthy London Partnership [email protected])

5.6 Health Integration Team Sheffield

Overview

The Health Integration Team (HIT), part of NHS South West Yorkshire Partnership NHS Foundation Trust, aims to facilitate the integration of people arriving from out of the UK into mainstream health services and address inequalities in health and wellbeing. The team has responsibility for newly arrived people in the asylum process who live in Barnsley, people seeking asylum under the age of 18 who are without any family, refugees, migrant workers and travellers within the local community. Support to patients includes a full health screening, information packs on the local area, TB screening clinics and healthcare checks in Initial Accommodation centres.



https://www.southwestyorkshire.nhs.uk/services/health-integration-team/#service-about


https://www.healthylondon.org/wp-content/uploads/2017/11/Homelessness-and-access-to-general-practice-training-slides.pdf


Staffing structure

The team consists of a Team Leader, who is also the Lead TB Nurse, two Specialist Nurses (one of whom also serves as a Mental Health Nurse), a Community Nurse (who also serves as a Community Nurse), and a Secretary.

FundingThis service is funded through Barnsley CCG.


It was locally recognised that improvements needed to be made to support the integration of migrants, including people in the asylum process in to mainstream health services, as well as addressing any inequalities in health and wellbeing of people from these communities. This was also influenced by Lord Darzi’s, ‘High Quality Care for All’, report for the Department of Health in 2008, where he outlined what good quality care should look like in the NHS.


The person centred, holistic approach at HIT has resulted in a very high level of patient satisfaction, with person satisfaction survey outcomes regularly receiving 98%. HIT also reports that people seeking asylum who use the service often bring other people to use the service.


A comprehensive screening process

Anyone seeking asylum who is dispersed to Barnsley is assessed by HIT and given a full health screening. During the screening process (which can take from 30-45 minutes), data is collected on demographics, lifestyle, diet, how a person arrived, any sexual health concerns and family history. They provide patients with a welcome pack with information on services in the Barnsley area, such as local dentists and opticians, to help them settle into the local community. HIT also provides weekly clinics for TB screening and carries out further health checks and minor ailment sessions in the Initial Accommodation centre.

A unique, nurse-led approach

An important aspect of HIT’s success is that it is nurse led. Staff feel that they do not have the same constraints that a GP or other doctor led service would have. For




instance, they can be more flexible with their time, allowing them to go into the community, and they are able to spend however long they choose with patients. They also believe that their previous nursing experience, working closely with in communities, plays an important role in their success.

Relationship building with both patients and organisations

In addition to having a dedicated staff team, an effective partnership model has been key to the success of HIT. They work well with different partners in the community, including Refugee Council, Voluntary Action Barnsley, MIND, IDAS, and GPs. G4S have all HIT staff contact details in all dispersal properties, and the housing support workers also know how to contact the team.

An example of the success of this collaborative approach is the formation of a women’s group/conversation club at a local library, which HIT set up jointly with Refugee Council and Voluntary Action. A nurse from HIT attends and participates in the conversation club, building a social relationship with the women who attend the group. A clinic is then held immediately after the session ends. If any health issues are presented and need to be followed up, the nurse refers patients to come in for a follow up appointment the same week.

HIT’s continued outreach with people seeking asylums has led to additional group sessions being established, such a men’s wellbeing group.

One of the reasons for their success is that HIT have focused on building a close, supportive and diverse staff team that can empathise with people. As one service user said: ‘I had no family. They are family.’

Contact

Beverley Jones ([email protected])





5.7 Family Refugee Support Project

Overview

The Family Refugee Support Project (FRSP) is a small part-time project based in Liverpool which started in 1999. FRSP provides psychological therapy using a human rights-based approach through horticulture in protected, safe, outdoor environments.

They work with people who are at any point in the asylum process (including people who have had an asylum claim refused), and people who have refugee status. The only eligibility criteria is that patients must be experiencing symptoms of trauma as a result of their experiences either in their home country or in the UK and must be a member of a family (they self-define what counts as ‘family’ – as long as there is one adult and a child under 18 years old).

Staffing structure

FRSP has four part-time staff – a director and senior counsellor (3.5 days a per week), a counsellor (1.5 days per week), an office manager (2.5 days per week) who has a lot of patient contact and has knowledge about the asylum process, and a horticulturist (3.5 days per week) who helps patients with their garden space (with whom patients can also raise issues). There is a group of trustees supporting the project, and a sub group to help with fundraising.

Funding

FRSP is funded by the Big Lottery Fund for 5 years (ending at the end of 2020), and Lloyd’s Foundation has also funded FRSP for 5 years (also ending in 2020).





People seeking asylum have often gone through diverse and traumatic experiences, both in their country of origin and during the process of seeking asylum in the UK. This can have a big impact on their mental health and on their family relationships. FRSP have found that normal psychological therapeutic approaches may not be appropriate, due to the specific needs of this group, and have instead adapted the approach, pace and time frames of their psychological therapy. The NHS does not usually offer such long term bespoke work, so families who are supported by the FRSP often feel as if their needs have not been met through NHS support.


FRSP’s approach has had a tremendous impact on patients. Patients report that they feel listened to, respected and energised to cope on a day-to-day basis, which helps them to maintain good mental health despite on-going difficulties. For example, during an FRSP focus group in 2018, when speaking about the services patients receive at FRSP, one patient remarked: ‘Here, we are people again’. Through FRSP, patients experience a lot of personal development, and some patients have also been able to support others who are going through similar experiences.


Healthcare and practical support

Patients have one hour, once a week, with a qualified and experienced psychological therapist to explore issues impacting on their mental health and wellbeing. Patients also receive support to help them communicate with GPs, or understand their prescriptions and hospital appointments.

Patients have additional time allocated once a week for a drop in session, where they can work through issues raised by the asylum process. This includes understanding the Right to Remain toolkit, letters from the Home Office and National Asylum Support Service, or working with existing and trustworthy resources to understand the law and good practice on health, education and access to legal support.

FRSP counsellors work with patients who are given leave to remain to help them understand their entitlements, such as housing and benefits. They help people to understand how to advocate for themselves on a long term basis. FRSP previously had a dedicated support worker to help with practical issues but due to lack of



https://righttoremain.org.uk/toolkit/


funding this post no longer exists. This works well because counsellors have already built a trusting relationship with patients.

A unique space

FRSP focus on ensuring that they provide an informal, private and confidential space to facilitate treatment. Meetings with therapists take place in gardens and allotments that are open but private, ensuring confidentiality but not replicating closed authoritative settings. A horticulturist at FRSP helps patients to look after their garden space. These gardens support families by providing them with a space to manage and call their own and to spend time in with their families.

An adapted approach to therapy

FRSP are flexible and adapt to patient needs. For example, people are increasingly being housed further away from the services that they need. FRSP feel it is important that their travel expenses are covered, so that patients can continue to benefit from the service.

They have also adapted the way in which they deliver psychological therapy. A traditional trauma model would consist of three phases: stabilisation, processing and integration. FRSP have found that the asylum seeking process has a profound impact on a person’s stabilisation, and that it is very difficult to force them to move on and process their trauma until they are in a stable position. A traditional therapy approach might focus on solely tackling psychological issues without addressing outside influences, with the result that moving to the ‘process’ phase quickly may be re-traumatising.

In contrast, FRSP focus on working at the right pace rather than in a specific time-frame or a set number of sessions. They assist people with the practical issues that are barriers to their stability before tackling their psychological issues and helping them through the next phases of processing and integrating. Their aim is not to get someone from one point to another as soon as possible, but to enable people to self-manage any traumatic experiences they have endured, or their experiences of the asylum process, and to learn from those past experiences to effectively manage present-day issues.

Contact

Jennie Geddes ([email protected])





5.8 TS4SE

Overview

TS4SE aims to support the integration of newly arriving communities and to improve communication and understanding across communities and services, both statutory and voluntary.

They provide training to people seeking asylum, and refugees and migrants on how to use the NHS. Alongside this they have a website that contains health information, resources and links for refugee and migrant communities, including information on the wider determinants of migrant health, mental health and wellbeing, and women, children and family health.

They provide in-service, face-to-face tailored training packages to NHS staff, including medical, nursing, dental, audiology and psychological wellbeing practitioners, on the health needs of refugees and asylum seekers, and the mental health implications of forced migration. TS4SE have also developed an online training toolkit, ‘Improving access to Health Care for Migrants: a toolkit’, which includes interactive learning modules and information packs on specific support areas, such as safeguarding.

Staffing structure

TS4SE has three directors and a pool of associates with specialist skills and/or experience in particular areas, including several people who have lived experience of seeking asylum.



https://ts4se-health-resources.org.uk/index.php


Funding

There is no regular funding for this project, with the team bidding for funding for projects on an ad hoc basis.


Through their work TS4SE have lots of engagement with other voluntary and community sector organisations. They recognised that there was a need for the local migrant and asylum sector to come together to align resources and expertise in order to work strategically with statutory bodies and services. Therefore they decided to form a conduit for all organisations working with migrant, asylum seeking and refugee communities, both voluntary and statutory, in North Manchester to come together to achieve better health outcomes for these groups.


People who work within the asylum system report that they have increased knowledge of the NHS as a result of taking part in TS4SE training. TS4SE have also been successful in supporting and influencing commissioners and other decision makers in understanding the complexities around the healthcare needs of asylum seekers and how to address them. This has helped commissioners to translate good ideas at a commissioning level into actual practice, thereby improving services for asylum seekers.


Specialised language support

TS4SE have developed and delivered community focused training sessions on how to use the NHS, delivered in the predominant languages spoken by people seeking asylum, refugees and migrants in the Greater Manchester area. They provide a questionnaire to attendees both before and after each session to determine prior knowledge of the NHS and measure any increase in knowledge. These questionnaires have demonstrated a marked increase in knowledge after the training has been delivered.

Influencing decision makers

Commissioners and healthcare professionals often see the health of asylum seekers as a specialist and complicated subject. TS4SE have supported commissioners and health professionals to understand the complexities around the healthcare needs of




asylum seekers and how to address them. They have helped commissioners to translate good ideas at a commissioning level into actual practice, thereby improving services for asylum seekers. For example:

While advising Manchester CCGs and Greater Manchester Health and Social Care Partnership on appropriate health provision for asylum seekers, TS4SE advocated for a new migrants service, which Manchester CCGs introduced over 2018/19. This service involved recruiting a number of GP surgeries and providing extra funding and training to them to learn about the needs of asylum seekers, to be able to better provide the healthcare that asylum seekers they are already entitled to.

TS4SE were commissioned by the Community Practitioners and Health Visitors Association to write a book on health care for asylum seekers and refugees entitled ‘Supporting the Health of Refugees and People Seeking Asylum: getting it right’. It is a free resource available to anyone who works with these groups. There are typically around 200 users per month. The toolkit is recommended in the Locally Commissioned Service documentation guidance for Manchester GPs.

In 2018, TS4SE were commissioned to write a section on refugees, asylum seekers and vulnerable migrants for the Manchester Joint Strategic Needs Assessment (JSNA). The intended audience is local commissioners of health services and as it is a part of the JSNA; there is a statutory requirement for commissioners to have regard to it.

In order to achieve long term, sustainable change for asylum seekers, TS4SE emphasise that when ideas are implemented, practice needs to be monitored to ensure that the ideas are being fully embraced and carried out. NHS Improvement have guidance on how best to implement improvements to practice, known as Plan, Do, Study, Act (PDSA) cycles.

Reaching out

In addition to training health practitioners and asylum seekers, TS4SE has co-produced videos in which asylum seekers have explained their experiences of and reasons for exile, and their health needs on arrival to the UK. They have delivered training to SERCO, the accommodation providers in the Northwest of England, on cultural competence and communication skills. They also have acted as a conduit for health professionals wishing to work with asylum seekers, recently facilitating the introduction of a drop-in for asylum seekers at the School of Dentistry at Manchester University. This has led to senior dental students offering dental health checks and follow up treatment to attendees at the drop-in.



https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf



https://ts4se-health-resources.org.uk/etraining/pdf/jsna.pdf




An Oxfam Cymru trainee reported that a TS4SE trainer…

‘…was excellent, his experience and knowledge was obviously extensive. His delivery was friendly and engaging. Even though our primary work isn’t with asylum seekers, it’s been an incredible insight and we feel much more prepared for supporting these clients.’

Contact

Cath Maffia ([email protected])





6 | Other examples of innovative practice

While gathering these case studies we were also signposted to other organisations who were doing good work. The organisations are as follows:

Organisation Region/city Type of service

Service provider

Key elements of practice

City Reach Health Services

Norwich, England

GP practice

NHS People seeking and refused asylum are screened and given immunisations, and support workers assist them with attending mainstream GP services near their accommodation. A volunteer psychiatrist attends once a month.

As a service, they aim to be easy to access, so when patients arrive they endeavour to create a supportive environment, including a simple registration process, no requirement for proof of address or immigration status, and a simple and flexible appointments system.

Camden Health Improvement Practice

London, England

GP practice

NHS CHIP provides access to healthcare by ensuring that people seeking and refused asylum are given access to GPs. They also provide





Service provider


(CHIP) interpreters (both in person and over the telephone) for patients and have links to a hostel for victims of modern slavery.

Those who are known to be seeking or refused asylum and have suffered mental trauma are given access to a mental health team who spend at least an hour with patients.

Royal Free NHS Foundation Trust

London, England

Support service

NHS The service supports people seeking asylum to attend HIV clinic appointments and to engage with wider necessary healthcare, with the aim of trying to improve hospital attendance for this group. The nurses also support people seeking asylum by signposting them to the local services in their area which can help with funds, accommodation, psychosocial support, immigration advice, social care support and any other support people might need.

Manchester Manchester, Health NHS This is a specialist HIV





Service provider


University NHS Foundation Trust

England support service

treatment and care clinic. When a patient indicates they are seeking asylum or are an undocumented migrant, it prompts further questions from the nurse that allow an assessment of whether the person seeking asylum has additional needs as a result of their immigration status.

Sahir House Liverpool, England

Support service

Third sector

This is a HIV support service providing direct support and referrals around all aspects of people’s needs, across a broad health and wellbeing remit, as well as engaging in a range of often very practical activities that ensure people attend the HIV clinic.

Share Tawe, Swansea City of Sanctuary

Swansea, Wales

Support service

Third Sector

Share Tawe offers hospitality to destitute people seeking asylum in Swansea. The scheme coordinator discusses health concerns and will help with attending appointments at GP surgeries and/or hospitals to help those people understand treatment options and processes.

Yaran Northwest

Manchester, England

Mental health service

Third sector

A multi-cultural team made up of fully qualified counsellors, psychotherapists and an





Service provider


advocacy advisor, this is often the first point of contact for newly arriving asylum seekers, assisting them with overcoming mental trauma, as well as overcoming barriers to accessing treatment (e.g. through being assessed within 2 weeks of referral). There are one to one appointments with clinicians and a group forum to discuss issues.

SOLACE Leeds, England

Mental health service

Third sector

SOLACE is a project working with people seeking asylum and those in the asylum system who are facing destitution. The service triages people who are referred by the local CCG and other health professionals in order to signpost them to other organisations, such as mental health specialists.

Refugee Council

England (wide)

Support service

Third sector

Refugee Council hosts a health befriending network for people seeking asylum and people granted refugee status who are living in four areas of England. A specific maternity befriending programme was developed in Leeds. The aim of the service is to ensure that pregnant women seeking asylum, or granted refugee status, understand their





Service provider


entitlements to maternity care in England in a timely manner, and to connect women to the local community.

Specialist Midwifery Service for Asylum Seekers and Refugees

Manchester, England

Nurse led service

NHS The aim of the service is to improve access to maternity care by developing an integrated service that meets the immediate health needs of women seeking asylum. They also support transitions following asylum claim decisions and ensures that health services are used appropriately.

Health integration team, Urban House (Wakefield)

Manchester, England

Nurse led service

NHS Urban House is an initial accommodation centre which houses people seeking asylum, which provides a nurse-led service to identify any health needs an individual may have. They provide emergency interventions, initial health checks and screening. All service users are also symptom screened for TB during their initial health check.

Birth Partner Project (BPP)

Cardiff, Wales

Maternity Support

Third sector

Birth Partner Project provides non-medical support for women who would otherwise who would have no alternative option for birth support. Support is provided during the pregnancy, birth and the first 8





Service provider


weeks after the birth.

BPP assists women with communicating with healthcare professionals, making sure women understand options and what they are being asked, and that women’s voices are heard, especially during the period of labour. BPP also assist women with accessing translation services where possible.

We are aware that this is by no means an exhaustive list of innovative practice across England Scotland and Wales.

We recommend that other researchers/interested organisations build on this suite of innovative practice, to gather further information about these organisations.




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Published April 2019

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